The Register Report, Fall 2007 Working Together: Integrated Health Care Expanding Psychologists' Clinical Roles by Ronald H. Rozensky, Ph.D. Return to Table of Contents

Stone (1991) recognized that there exists “… a core of knowledge and technique common to all practice of psychology” and “competence acquired elsewhere must be modified and extended if proficiency in medical settings is to be achieved” (p xii). Stone went on to say there is indeed “functional specialization” within medical settings based upon the time it takes an individual psychologist to reach a journeyperson level of competence in some specific area of practice (p xi). Rozensky, Sweet and Tovian (1991) recognized a spectrum of professional titles, or specialties, for the scope of activities undertaken by clinical psychologist in medical settings and in working with medical patient including health psychology, medical psychology, clinical health psychology, neuropsychology, rehabilitation psychology, behavioral medicine, primary care psychology, pediatric psychology, integrative medicine, and clinical psychology. Matarazzo’s (1987) declared that there is only one psychology, no specialties, with many applications.

In practice, psychologists have functioned as practitioners and carried out research in medical settings and with medical patients for many years. For example, primary care has been seen by many as a relatively new endeavor for psychologists “even though psychologists have functioned as de facto primary care providers during a sizable part of our history” (Newman and Rozensky, 1994; p. 3). Similarly, while the American Psychological Association (APA) only changed its bylaws to include health in its mission in 2001 stating that APA’s mission is now “to advance psychology as a science and profession, and as a means of promoting health and human welfare” (Johnson, 2004), the Arden House Conference in 1983 had already acknowledge the growing field of clinical health psychology (Stone, 1983). Clearly, psychologists have been involved in medical care for many, many years even while many practitioners are seeking to expand there practices into this arena today. Belar, Brown, Hersch, Hornyak, Rozensky, Sheridan, Brown, and Reed (2001) offer those practitioners a model of self study that can be used to “assess their readiness to provide services to patients with physical health problems” (p. 136).

This article will present information about the range of medical disorders towards which psychologists can direct their practices, the self study questions that will help with the ethical expansion of practice, and HIPAA and practice issues focused upon the practice of psychology in medical settings and with medical patients.

THE RANGE OF DISEASES AND PATIENT TYPES WITH WHICH PSYCHOLOGISTS CAN WORK

To illustrate the range of medical problems psychologists study and treat, Rozensky (2006) reviewed some 481 articles published in the Journal of Clinical Psychology in Medical Settings across a thirteen year period. Table I presents, by diagnosis or presenting complaint and key words in the title or abstract of the paper, the twenty three most common topics written about during that period.

Additional topics included obesity in adults and children, Parkinson’s disease, infertility, HIV/AIDS, Hepatitis C, brain tumors & brain injury, and ADHD. Each had several articles that concentrated on them. Highly prevalent disorders, and those not so prevalent, also included such diverse topics as urinary incontinence, spina bifida, sleep apnea, irritable bowel, prostatectomy, postpartum depression, smoking control, aging, menopause, psychological and behavioral health diagnoses, low birth weight, and eating disorders in men, to name just a few of many.

Clearly, most of the major diseases and medical problems of the human condition were covered along with psychologists’ scientific and clinical work with cancer patients, pain, spinal cord injury, chronic illnesses, heart disease, sickle cell disease and asthma that predominated in the journal. The largest general topic of study was that of organ transplantation (31) with heart (9), lung (6), liver (5), and bone marrow (5) transplantation as the primary topics within that category. Rozensky concluded that, when you include the various transplanted organs to the general count of articles, “you see a pattern not too dissimilar from that of the death rates in the United States as published by the Centers for Disease Control” (p. 348) (CDC; Minino, Heron, and Smith, 2006). Further, the top 15 causes of death, according to the CDC included, in rank order, diseases of the heart, malignant neoplasms, cerebrovascular disease, chronic lower respiratory disease, accidents, diabetes mellitus, Alzheimer’s disease, influenza and pneumonia, nephritis, septicemia, suicide, chronic liver disease and cirrhosis, essential hypertension, Parkinson’s disease, and pneumonia. And the National Center for Health Statistics (2005) provides data on chronic health conditions causing limitations of activity and impact on actual quality of life. Those data, across the life span from childhood to older adulthood, presented by the number of individuals per 100,000 of the population with each disorder shows that for children through age 17, problems such as speech disorders, asthma, developmental disorders, emotional and behavioral problems, and ADHD and learning problems predominate as limitations to activity. Mental illness and arthritis predominate in young adults, while arthritis, heart disease, diabetes, lung disease, fractures, and mental illness impose greater limitations on those over age 55. Arthritis, heart or circulatory diseases, hearing and vision problems, diabetes, lung disease, and senility cause the greatest limitations of activity for individuals over 65 years of age.

Reviewing the topics covered by one journal publishing in the area of health psychology for more than a decade, illustrates that psychologists do indeed study and provide clinical services to patients with the major diseases that shorten life or cause limitations to the experience of a quality life.

ASSURING ETHICAL AND COMPETENT EXPANSION OF PRACTICE

The APA (2002) Ethical Principles and Code of Conduct states that psychologists should only practice within the boundaries of their competency (p. 4). To assure that this ethical responsibility is met when expanding one’s practice to work with medically ill patients, Belar and colleagues (2001) offer a model for self assessment and continuing education that facilitates that ethical expansion of practice into the domain of clinical health psychology. These authors suggest that, before traditionally trained, mental health focused psychologists (who might have had only an introduction to health psychology during graduate school) seek to work clinically with medically ill patients, they should “develop the necessary expertise to provide quality services across a broader range of health problems” (p. 136). Thus, in preparation for the assessment and treatment of medically ill patients, they suggest that clinicians ask themselves 13 questions to self-assess readiness to deliver these services. This self-assessment should be used by clinicians in a hospital-based practice or those who want to expand their clin ical work and begin seeing patients with a medical diagnosis new to their practice. The self-study questions recommended by Belar et al. (2001, p. 137) are as follows:

Do I have knowledge of the biological bases of health and disease as related to this problem? How is this related to the biological bases of behavior?

Do I have knowledge of the cognitive-affective bases of health and disease as related to this problem? How is this related to the cognitive-affective bases of behavior?

Do I have knowledge of the social bases of health and disease as related to this problem? How is this related to the social bases of behavior?

Do I have knowledge of the developmental and individual bases of health and disease as related to this problem? How is this related to developmental and individual bases of behavior?

Do I have knowledge of the interactions among biological, affective, cognitive, social, and developmental components (e.g., psychophysiological aspects)?

Do I understand the relationships between this problem and the patient and his or her environment (including family, healthcare system, and sociocultural environment)?

Do I have knowledge and skills of the empirically supported clinical assessment methods for this problem and how assessment might be affected by information in areas described by Questions 1–5?

Do I have knowledge of, and skill in implementing, the empirically supported interventions relevant to this problem? Do I have knowledge of how the proposed psychological intervention might impact physiological processes and vice versa?

Do I have knowledge of the roles and functions of other health-care professionals relevant to this patient’s problem? Do I have skills to communicate and collaborate with them?

Do I understand the sociopolitical features of the healthcare delivery system that can impact this problem?

Do I understand the health policy issues relevant to this problem?

Am I aware of the distinctive ethical issues related to practice with this problem?

Am I aware of the distinctive legal issues related to practice with this problem? Am I aware of the special professional issues associated with this practice with this problem?

These questions challenge clinicians to understand the interplay of all aspects of the biopsychosocial dimensions of the disease and to have a working knowledge of the empirically supported assessments and treatments for the management of the disorder and its contributing psychological factors or sequelae. Answers to these questions also readily prepare the clinician to communicate with members of the health care team, including the patient, and to conceptualize problems in a truly integrative manner (Tovian, 2006) in settings from primary to tertiary care. continued

 

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